Nursing Elites

1. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain a sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw the catheter in a circular motion

Correct answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

2. Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?

• A. All 4 side rails up, wheels locked, bed closest to door
• B. Lower side rails up, bed facing the doorway
• C. Knees bent, head slightly elevated, bed in the lowest position
• D. Bed in the lowest position, wheels locked, place bed against the wall

Correct answer: D

Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.

3. A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?

• A. I need to wear a mask when I go out in public to prevent spreading the infection.
• B. I need to take my medication as prescribed to prevent spreading the infection to others.
• C. I need to cover my mouth when I cough to prevent spreading the infection.
• D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.

Correct answer: A

Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.

4. The client is preparing for a myelogram. Which of the following statements by the client indicates a contraindication for this test?

• A. I can't lie in one position for more than thirty minutes.
• B. I am allergic to shrimp.
• C. I suffer from claustrophobia.
• D. I developed a severe headache after a spinal tap.

Correct answer: B

Rationale: An allergy to shrimp is a contraindication for a myelogram because the contrast dye used in the procedure contains iodine, which can trigger allergic reactions in individuals allergic to shellfish. Choices A, C, and D are not contraindications for a myelogram. Inability to lie still for an extended period, claustrophobia, or a previous headache after a spinal tap are concerns that can be managed during the procedure but do not necessarily prevent the test from being performed.

5. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?

• A. Obtain a 12-lead EKG
• B. Place the client in high Fowler's position
• C. Lower the oxygen rate
• D. Take baseline vital signs

Correct answer: C

Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.

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